Sociodemographic and lifestyle correlates of exclusive breastfeeding practices among mothers on antiretroviral therapy in the Eastern Cape, South Africa

Exclusive breastfeeding (EBF) could save the lives of infants and prevent mother-to-child transmission (PMTCT) of HIV infection [1, 2], especially in a country like South Africa with a high HIV burden [3, 4]. Between 2010 and 2015, South Africa has made policy changes in infant feeding practices and PMTCT guidelines. The policy changes resulted in the replacement of free infant formula for EBF for 6 months policy. Mothers are counselled to practice EBF in the first 6 months, continue to breastfeed beyond 6 months whilst introducing complementary feeding. Also, the new policy recommended the adoption of WHO Option B+ (lifelong antiretroviral therapy strategy) for all HIV-infected pregnant and postpartum women, irrespective of their immune suppression status or infant feeding choice [1, 5, 6].

Established global evidence has shown that exclusive breastfeeding prevents both the incidence of and mortality from diarrhoea, which is commonly associated with mixed feeding practices and infant formula feeding practices [7]. Overall, EBF confers the benefits of essential nutrients and robust immune systems, reduction in the risk of malnutrition and diarrheal associated-illnesses, which are the leading causes of infant mortality in developing nations [1, 8‐10]. Worryingly, even with available data demonstrating unequivocal benefits of EBF, mothers often do not abide by the recommended 6 months of EBF [11‐13], thus, putting infants at high risk of death. The low EBF prevalence is underpinned by several factors, thus suggesting that there is more to learn and understand regarding the prevailing reasons for the reluctance of mothers to breastfeed their infants exclusively. Previous studies conducted in South Africa have indicated contradictory infant feeding messages from older relatives, such as grandmothers, and healthcare workers, low socio-economic indicators, and the fear of transmitting HIV to the infant as among the reasons for mixed-feeding practices [10, 14].

Exclusive breastfeeding prevalences are reportedly low in many countries, despite the manifold benefits accruable from breastfeeding [15‐17]. As reported by Victoria et al. [16] study, only 37% of children are exclusively breastfed in developing countries. In sub-Saharan Africa, the prevalence of EBF is 36% [17], which is very low compared with the global EBF target prevalence set at 50% by 2025 [18]. In South Africa, the government effort has yielded some modest improvement in the prevalence of EBF among mothers living with HIV over the years [19]. However, with an estimation of 31.6% EBF prevalence, the country remains below global targets [15, 20, 21]. The fear of HIV transmission and status disclosure is among the reasons for the low prevalence of exclusive breastfeeding [22, 23].

Considering the high HIV epidemic in South Africa, with approximately 7.7 million people with HIV [24], understanding the factors associated with EBF is essential in crafting strategies to support and sustain appropriate breastfeeding practices to increase the prevalence of exclusive breastfeeding. Even though previous studies have examined the prevalence of EBF among lactating mothers living with HIV in South Africa [10, 15, 17, 20, 25‐28], scanty information exists in the Eastern Cape, a province with a twin burden of HIV epidemic and poverty. Given that factors affecting EBF practices vary among countries and even within the sub-groups of populations [29], contextual information on the prevalence and determinants of EBF is vital to inform context-specific interventions. Hence, this study seeks to examine the prevalence and the factors influencing EBF practices among mothers receiving antiretroviral therapy (ART) in the Eastern Cape Province, South Africa.

The participants’ mean age was 33 ± 5.7 years. The majority of the participants were 30 years and above (69.3%), single (66.3%), had grade 12 level of education (87.4%), unemployed (61.8%), and were on government social grant (94.5%). Only a few participants smoked (8.1%) or drank alcohol (35.4%) (Table 1).

Our study aimed to examine the prevalence and factors influencing six-month EBF practice among mothers on ART in the Eastern Cape Province, South Africa. Although programmes on 6 months of infant breastfeeding have been developed and approved in South Africa, the uptake of EBF remains low. In this study, the prevalence of six-month EBF of 32.0% was sub-optimal. However, direct comparison of EBF prevalence in this study with many other studies on EBF practice is a difficult task, given the variations in the definitions of EBF in different studies, the timing, duration of recall, methods of analysis, and sample biases [32]. Notwithstanding, the EBF prevalence obtained in this study is comparable to 31.6% among infants exclusively breastfeed for the first 6 months after delivery in Malawi, which was measured by recall method [33].

Generally, the low prevalence of EBF in South Africa is worrying and suggests concerted interventions to promote, support, and protect breastfeeding, beyond policy and programme formulations are needed. Some studies in other provinces in South Africa reported higher EBF prevalence at 43.2% among HIV-positive mothers in Merafong sub-district in Gauteng [34], and 35.6% in Gert Sibande district in Mpumulanga [35]. An earlier study by Siziba et al. [25] reported a low summative prevalence of 12.0% in North-West, Gauteng, Free State, and Eastern Cape Provinces. Also, 18.0, 6.0, 13.0, 7.6, and 6.7% of mothers practiced EBF up to 6 months in Kwa-Zulu Natal, Western Cape, Limpopo and Gauteng provinces, respectively [36‐40]. Compared with other settings elsewhere, the EBF prevalence in our study is almost at par with prevalences reported in Ethiopia (30.6, 31.0%) [41, 42], Bangladesh (35.0%) [43] and India (34.0%) [44], but higher than the EBF prevalence reported in Kaiyuan Yunnan, Southwest China (27.34%) [45], Saudi Arabia (24.4%) [46], USA (16.8%) [47], Egypt (9.7%) [48] and Nigeria (14.8%) [49]. Yet, other studies have reported higher EBF prevalence in Ethiopia (88.8, 75.2%; 77.3%) [28, 50, 51], Kenya (71.4%; 52.3%) [52, 53], Western India (61.5%) [54] and Tanzania (55.5%) [55]. The differences in EBF prevalences reported across various countries or regions in the literature could be explained in the light of differences in the definition of EBF and geographic variations in the interplay of cultural, economic, and sociodemographic factors affecting exclusive breastfeeding.

Notwithstanding the many advantages of breastfeeding and the strategies to promote it, EBF uptake still remains low in many developing countries [16, 56]. Worryingly, worldwide, only 35% of infants are exclusively breastfed [57]. Exclusive breastfeeding is associated with a reduction in child mortality in low-income countries [58, 59]; thus, interventions on EBF should be accorded top priority. In this regard, there is a need to sensitise the community on the benefits and inherent problems associated with mixed feeding [47]. In the South African context, one of the pragmatic approach to promote women’s awareness of EBF, outside of health facility channels, could be to utilise and encourage the Ward-Based-Outreach-Teams (WBOT) in the community or women’s groups to increase the duration of EBF. One of the cardinal objectives of WBOT is to promote and create awareness on various health issues affecting the community as part of the government efforts of improving the primary healthcare re-engineering agenda. This is advisable because community beliefs could have considerable influence on EBF practice.

Our findings demonstrated that being unemployed and having a low level of education (secondary or less) was significantly associated with a higher likelihood of exclusive breastfeeding. In contrast, alcohol use was significantly associated with lower odds of six-month exclusive breastfeeding practice. Previous studies have linked maternal employment with lower prevalences of EBF and earlier cessation of breastfeeding [60, 61]. In this study, consistent with studies conducted in Bangladesh [43], Saudi Arabia [46], Ethiopia [62‐64], Tanzania [65], Canada [66], and Guatemala [67], unemployed mothers are likely to practise EBF as compared to those who are employed. It is plausible that mothers who are not employed do have enough opportunity while at home to breastfeed their infants. Contrastingly, employed mothers, perhaps due to the nature of their work with the challenge to return early to work after giving birth, work shifts, and maternal fatigue, may collectively hinder them from having frequent contact with their infant to provide exclusive breastfeeding. In South Africa, working mothers are granted only 4 months of maternity leave, which may begin at any time from at least 4 weeks before the birth of the baby, and there are no available workplace facilities for mothers to breastfeed children. The Code of Good Practice on the protection of employees during pregnancy and after childbirth included in the Basic Conditions of Employment Act (Republic of South Africa, 1997), stipulated that arrangement should be made to accommodate employees who are breastfeeding, with 30 min breastfeeding breaks twice a day to breastfeed or express for the first 6 months of the child’s life (paragraph 5.13) (the Republic of South Africa, Department of Labour, 1998). However, the actual situation is that women employees and their employers are mostly unaware of this legislation on breastfeeding breaks [68, 69], which are seldom provided or requested in the workplace. Policies about maternity leave in South Africa warrant scrutiny to encourage EBF practice. This is very crucial in the context of achieving comprehensive PMTCT.

In this study, mothers with a low level of education are inclined to practise exclusive breastfeeding. Previous studies have reported similar findings [43, 70‐73]. However, Mango et al. [16] study in Tanzania found the level of education had no association with EBF practice. Other studies conducted in Ethiopia and Bangladesh reported similar findings [74, 75]. The association of a lower level of education with EBF could be explained by the higher rate of unemployment in this population. As such, strategies aimed at strengthening EBF practise in this population should also address the needs of women with higher levels of education. Specifically, the concerns and fears of educated women need to be addressed during counselling sessions at antenatal and postnatal clinics.

This study revealed that alcohol use was significantly associated with lower odds of six-month exclusive breastfeeding practice. About 22.9% of mothers drink alcohol. A survey conducted in the Kilimanjaro region, Tanzania, showed that mothers’ alcohol intake was associated with EBF up to 6 months [73]. Other studies have reported similar findings elsewhere [70‐72, 76]. However, Mgongo et al. [56] reported a contrary result. Previous studies have linked alcohol intake with HIV and poor child immunisation [77, 78]. A recent study has reported high binge drinking (10.8%) among women in South Africa [79]. Alcohol consumption is widely practised in South Africa [79], at various events or celebrations such as weddings, burials, and other social events, work or community engagements. Advocacy programmes on the effects of alcohol intake during lactating are crucial. Alcohol use, whilst breastfeeding, has negative effects on newborns, EBF, and general infant growth [80, 81].

The prevalence of exclusive breastfeeding in the study, although comparable with sub-Saharan Africa and worldwide prevalence, remains suboptimal. Interventions aimed at promoting, supporting, and protecting breastfeeding beyond policy and programme formulations are urgently needed in the region. The factors affecting the EBF of HIV-positive mothers in this study include employment, low levels of education, and alcohol consumption. A general advocacy campaign on exclusive breastfeeding must target alcohol cessation and the creation of a favourable workplace environment for lactating mothers.